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Pathology reports (view source)

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'''Sign out''' is the finalization of a case.  The term comes from when one used to actually sign the reports.
'''Pathology reports''' are what [[pathologist]]s produce when finishing a case. '''Sign out''' is the finalization of a case.  This article discusses both.


==Rules==
The term ''sign out'' is from when one used to actually sign the reports.
*Diagnostic line should end with a period.
 
The key point in report writing is that the report should be precise, complete and easy-to-understand.  Many pathology reports, unfortunately, are misunderstood by surgeons; one study suggests that it is 30%!<ref name=pmid10888781>{{Cite journal  | last1 = Powsner | first1 = SM. | last2 = Costa | first2 = J. | last3 = Homer | first3 = RJ. | title = Clinicians are from Mars and pathologists are from Venus. | journal = Arch Pathol Lab Med | volume = 124 | issue = 7 | pages = 1040-6 | month = Jul | year = 2000 | doi = 10.1043/0003-9985(2000)1241040:CAFMAP2.0.CO;2 | PMID = 10888781 }}</ref>
 
==Standards==
Based on a PubMed search,<ref>URL: [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=PureSearch&db=PubMed&details_term=standardization,%20surgical%20pathology%20report Pubmed search for ''standardization, surgical pathology report'']. </ref> the first papers on the topic of standards were written in 1992!<ref name=pmid1574498>{{cite journal |author=Rosai J, Bonfiglio TA, Corson JM, ''et al.'' |title=Standardization of the surgical pathology report |journal=Mod. Pathol. |volume=5 |issue=2 |pages=197–9 |year=1992 |month=March |pmid=1574498 |doi= |url=}}</ref><ref name=pmid1574486>{{cite journal |author=Frable WJ, Kempson RL, Rosai J |title=Quality assurance and quality control in anatomic pathology: standardization of the surgical pathology report |journal=Mod. Pathol. |volume=5 |issue=2 |pages=102a–102b |year=1992 |month=March |pmid=1574486 |doi= |url=}}</ref>
 
There is no universal standard; however, there is a push to standardize by the ''Association of Directors of Anatomic and Surgical Pathology'',<ref>URL: [http://www.adasp.org/papers/position/Standardization.htm http://www.adasp.org/papers/position/Standardization.htm]. Accessed on: 6 September 2012.</ref> among others.
 
Standards appear to lead to uniformity and consistency.<ref name=pmid7878300>{{cite journal |author=Leslie KO, Rosai J |title=Standardization of the surgical pathology report: formats, templates, and synoptic reports |journal=Semin Diagn Pathol |volume=11 |issue=4 |pages=253–7 |year=1994 |month=November |pmid=7878300 |doi= |url=}}</ref>
 
Something close to a standard is laid-out in by Goldsmith et al.<ref name=pmid18834219>{{Cite journal  | last1 = Goldsmith | first1 = JD. | last2 = Siegal | first2 = GP. | last3 = Suster | first3 = S. | last4 = Wheeler | first4 = TM. | last5 = Brown | first5 = RW. | title = Reporting guidelines for clinical laboratory reports in surgical pathology. | journal = Arch Pathol Lab Med | volume = 132 | issue = 10 | pages = 1608-16 | month = Oct | year = 2008 | doi = 10.1043/1543-2165(2008)132[1608:RGFCLR]2.0.CO;2 | PMID = 18834219 }}</ref>
 
===Checklists===
{{Main|CAP checklists}}
The College of American Pathologists (CAP) has checklists for cancer - [http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=committees%2Fcancer%2Fcancer_protocols%2Fprotocols_index.html&_state=maximized&_pageLabel=cntvwr CAP protocols].
 
It seems likely that pathologists will use more checklists in the future... they are deemed effective in a number of places inside and outside of medicine.  Good evidence suggests that surgical checklists reduces adverse events.<ref name=pmid19158173>{{cite journal |author=Soar J, Peyton J, Leonard M, Pullyblank AM |title=Surgical safety checklists |journal=BMJ |volume=338 |issue= |pages=b220 |year=2009 |pmid=19158173 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=19158173}}</ref> Pilots have been using checklists since the 1930s.<ref name=gawande>Gawande A. The checklist manifesto: How to get things right. Metropolitan Books. 2009. URL: [http://www.amazon.com/dp/0805091742 http://www.amazon.com/dp/0805091742]. ISBN-13 978-0805091748.</ref>
 
===Standard diagnostic notation===
 
Site, operation/procedure:<br>
- Tissue type diagnosis.
 
 
Example:
<br>
Gallbladder, cholecystectomy:<br>
- Acute cholecystitis.
 
==Formatting recommendations used on ''Libre Pathology''==
===Diagnosis===
*The tissue type/site usually should be what the clinician submitted it as.
**Lay terms are preferred in some circumstances (e.g. ''stomach'' instead of ''gastric''), as the patients often read their pathology reports.
*The tissue type should be the first thing in the diagnostic line if it is not obvious from the diagnosis, e.g. ''gastric body-type mucosa''.
*If several diagnoses are made, the most clinically important diagnosis should be listed first.
*Each diagnostic line should end with a period or semicolon.
**Punctuation experts are somewhat divided on what to do here.<ref>URL: [http://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html phttp://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html]. Accessed on: 10 January 2014.</ref><ref>URL: [http://www.ossweb.com/article-bullets.html http://www.ossweb.com/article-bullets.html]. Accessed on: 10 January 2014.</ref>
**The advantage of using a period or semicolon is: the end the diagnostic line is clearly marked.
*It is best to avoid ''no'' and ''not'', as these may be lost at transcription or overlooked.<ref>{{Cite journal  | last1 = Renshaw | first1 = MA. | last2 = Gould | first2 = EW. | last3 = Renshaw | first3 = A. | title = Just say no to the use of no: alternative terminology for improving anatomic pathology reports. | journal = Arch Pathol Lab Med | volume = 134 | issue = 9 | pages = 1250-2 | month = Sep | year = 2010 | doi = 10.1043/2010-0031-SA.1 | PMID = 20807042 }}</ref>
**''Negative'' and ''without'' are preferred.
 
====Uncertainty====
*Uncertainty in reports can be conveyed with various terms.
*There is no standard but the interpretation (by clinicians and pathologists) of various phrases have been compared by Lindley ''et al.'' using a scale of 0 (uncertain)  to 100 (certain):<ref name=pmid24939143>{{Cite journal  | last1 = Lindley | first1 = SW. | last2 = Gillies | first2 = EM. | last3 = Hassell | first3 = LA. | title = Communicating diagnostic uncertainty in surgical pathology reports: disparities between sender and receiver. | journal = Pathol Res Pract | volume = 210 | issue = 10 | pages = 628-33 | month = Oct | year = 2014 | doi = 10.1016/j.prp.2014.04.006 | PMID = 24939143 }}</ref>
**''Cannot rule out'' (55) and ''indefinite for ...'' (52) convey the highest level of uncertainty among attending clinicians.
**''Suggestive of ...'' (57) conveys a lesser level of uncertainty.
**''Consistent with ...'' (76) seems to be ignored by many.
 
====Abbreviations====
*[[Abbreviations]] should not be used, e.g. [[LEEP]] should be written-out as ''loop electrosurgical excision procedure''.
**Patients often read their reports. Abbreviations muddle things.
 
===Microscopic===
:[[AKA]] ''microscopy''.
*Describes how the tissue looks under the microscope.<ref>URL: [http://www.cancer.gov/cancertopics/factsheet/detection/pathology-reports http://www.cancer.gov/cancertopics/factsheet/detection/pathology-reports]. Accessed on: 24 April 2014.</ref>
 
Notes:
*One should ''not'' assume it is going to be read by the clinician.
**If it is essential to read, a comment in the diagnosis section, that says ''see microscopic'', is advisable.
*Immunostains should be reported as a comment in the ''diagnosis'' section.
**Many labs report IHC in the ''microscopic'' section.<ref name=pmid18834219>{{Cite journal  | last1 = Goldsmith | first1 = JD. | last2 = Siegal | first2 = GP. | last3 = Suster | first3 = S. | last4 = Wheeler | first4 = TM. | last5 = Brown | first5 = RW. | title = Reporting guidelines for clinical laboratory reports in surgical pathology. | journal = Arch Pathol Lab Med | volume = 132 | issue = 10 | pages = 1608-16 | month = Oct | year = 2008 | doi = 10.1043/1543-2165(2008)132[1608:RGFCLR]2.0.CO;2 | PMID = 18834219 }}</ref>
*Internal reviews/consults should likewise not be found here; they should be in a comment in the ''diagnosis'' section.


==Report sections/elements==
==Report sections/elements==
===Addendum===
===Addendum===
*Formally ''report addendum''.
*Formally called ''report addendum''.
*Used to add material to the report.
*Used to add material to the report.
*Generally, the new material should not substantially contradict the opinion the report.
*Generally, the new material should not substantially contradict the opinion offered by the report.


===Amendment===
===Amendment===
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==Dealing with errors==
==Dealing with errors==
{{Main|Quality}}
*Opinion is split on whether reports should be ''amended'' or ''addended''.
*Opinion is split on whether reports should be ''amended'' or ''addended''.


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*[[Basics]].
*[[Basics]].
*[[MEDITECH]].
*[[MEDITECH]].
*[[Pathology requisitions]].
==References==
{{Reflist|2}}


==External links==
*[http://www.cancer.gov/cancertopics/factsheet/detection/pathology-reports Pathology reports (cancer.gov)].
*[http://ww5.komen.org/BreastCancer/ContentsofaPathologyReport.html Pathology reports (komen.org)].
[[Category:Stuff]]
[[Category:Stuff]]
Michael
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